Update on Regional Anaesthesia in Intraocular Surgery

Abstract

Background: Retrobulbar anaesthesia is a valuable alternative not only for polymorbid and haemodynamically compromised patients. Complications are rare but may be devastating. Methods: Principally, any intraocular surgery can be made under local anaesthesia. There are only a few contraindications to regional anaesthesia such as denial against regional anaesthesia, allergy to local anaesthetics, local infection, severe orthopnea, insufficiently controlled psychiatric disorders or small children and non-cooperative patients. Results: The success rate of retrobulbar anaesthesia in terms of control of intraoperative discomfort approaches 100 % with an intraconal injection in 94 % and a distribution of fluid into the intraconal space in 97 %. Conclusion: Based on the recent literature, the present review compares techniques, describes possible complications and in the absence of evidence-based studies provides suggestions for the handling of patients under thrombocyte aggregation inhibitor and vitamin K antagonist therapy and anticoagulation.

Zusammenfassung

Hintergrund: Die Retrobulbäranästhesie ist eine wertvolle Alternative zur Allgemeinanästhesie nicht nur für polymorbide Patienten. Komplikationen sind selten, aber wenn, dann schwer. Methoden: Grundsätzlich kann jeder intraokulare Eingriff in Retrobulbäranästhesie durchgeführt werden. Zu den wenigen Kontraindikationen gehören die Ablehnung der Patienten, Allergie gegen Lokalanästhetika, lokale Infektionen, Atemnot und nicht sicher kontrollierte psychiatrische Erkrankungen sowie Operationen bei kleinen Kindern und nicht kooperativen Patienten. Ergebnisse: Die Erfolgsrate von Retrobulbäranästhesien bezüglich intraoperativer Beschwerdefreiheit liegt bei annähernd 100 %. Eine intrakonale Injektion ist bei korrekter Technik in 94 % und eine Verteilung der Anästhetica in den intrakonalen Raum in 97 % zu erreichen. Schlussfolgerung: Basierend auf der verfügbaren jüngeren Literatur vergleicht die vorliegende Übersicht die verschiedenen Techniken der periokulären Anästhesie, stellt mögliche Komplikationen und bei Fehlen evidenzbasierter Studien Vorschläge zum Umgang mit Patienten unter Thrombozytenaggregationshemmer-Therapie, Vitamin-K-Antagonisten und Antikoagulation vor.

Schlüsselwörter

Retrobulbär-Anästhesie - Peribulär-Anästhesie - Sicherheit - fibrinolytisch wirksame Medikamente/Fibrinolytika - Thrombozyten-Aggregationshemmer - Methoden zur Nervenblockade

Key words

retrobulbar anesthesia - peribulbar anaesthesia - safety - fibrinolytic agents - thrombocyte aggregation inhibitors - nerve block methods

• References

• 1 Duschinksi C. Analyse des Patientengutes in der Kataraktchirurgie in Bezug auf die Auswahlkriterien einer ambulanten oder stationären Behandlung [Dissertation]. Münster: Westfälische Wilhelms-Universität; 2003: 17
• 2 Jain VK, Lawrence M. Peribulbar versus retrobulbar anesthesia. Int Ophthalmol Clin 1994; 34: 33-42
• 3 Gayer S, Kumar CM. Ophthalmic regional anesthesia techniques. Minerva Anestesiol 2008; 74: 23-33
• 4 Atkinson WS. Retrobulbar injection of anesthetic within the muscular cone. Arch Ophthalmol 1936; 16: 494-503
• 5 Hessemer V. [Peribulbar anesthesia versus retrobulbar anesthesia with facial nerve block. Techniques, local anesthetics and additives, akinesia and sensory block, complications]. Klin Monatsbl Augenheilkd 1994; 204: 75-89
• 6 Jankovic D. Regionalblockaden & Infiltrationstherapie: Lehrbuch und Atlas. Berlin: ABW Wissenschaftsverlag GmbH; 2008
• 7 Calenda E, Genevois O, Cardon A et al. Peribulbar anesthesia in 750 patients treated with oral anticoagulants. Int J Ophthalmol 2014; 7: 110-113
• 8 Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal surgery. Am J Ophthalmol 2011; 151: 934.e3-939.e3
• 9 Passemard M, Koehrer P, Juniot A et al. Maintenance of anticoagulant and antiplatelet agents for patients undergoing peribulbar anesthesia and vitreoretinal surgery. Retina 2012; 32: 1868-1873
• 10 Narendran N, Williamson TH. The effects of aspirin and warfarin therapy on haemorrhage in vitreoretinal surgery. Acta Ophthalmol Scand 2003; 81: 38-40
• 11 Lip GY, Durrani OM, Roldan V et al. Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract 2011; 65: 361-371
• 12 Mason 3rd JO, Gupta SR, Compton CJ et al. Comparison of hemorrhagic complications of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group. Ophthalmology 2011; 118: 543-547
• 13 Bauer KA. Pros and cons of new oral anticoagulants. Hematology Am Soc Hematol Educ Program 2013; 2013: 464-470
• 14 Bonhomme F, Hafezi F, Boehlen F et al. Management of antithrombotic therapies in patients scheduled for eye surgery. Eur J Anaesthesiol 2013; 30: 449-454
• 15 Luyet C, Eichenberger U, Moriggl B et al. Real-time visualization of ultrasound-guided retrobulbar blockade: an imaging study. Br J Anaesth 2008; 101: 855-859
• 16 Palte HD, Gayer S. Ultrasound investigation and the eye (comment). Anesthesiology 2012; 117: 1396-1397
• 17 Kumar CM. Orbital regional anesthesia: complications and their prevention. Indian J Ophthalmol 2006; 54: 77-84
• 18 Rubin AP. Complications of local anaesthesia for ophthalmic surgery. Br J Anaesth 1995; 75: 93-96
• 19 Katz J, Feldman MA, Bass EB et al. Study of Medical Testing for Cataract Surgery Team. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology 2003; 110: 1784-1788
• 20 Eke T, Thompson JR. The National Survey of Local Anaesthesia for Ocular Surgery. II. Safety profiles of local anaesthesia techniques. Eye (Lond) 1999; 13: 196-204
• 21 Cionni RJ, Osher RH. Retrobulbar hemorrhage. Ophthalmology 1991; 98: 1153-1155
• 22 Puustjarvi T, Purhonen S. Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery. Ophthalmic Surg 1992; 23: 450-452
• 23 Nicol M. Anaesthesia for ophthalmic surgery. In: Aitkinhead AR, Rowbotham DJ, Smith G, eds. Textbook of Anaesthesia. London: Churchill Livingstone; 2001
• 24 Kumar CM. Needle-based blocks for the 21st century ophtalmology. Acta Ophthalmol 2011; 89: 5-9
• 25 Carneiro HM, Teixeira KI, de Avila MP et al. A comparative study between 25 × 0.70 mm and 20 × 0.55 mm needles for retrobulbar block with small volume of anesthetic for the treatment of cataracts by phacoemulsification. Rev Bras Anestesiol 2008; 58: 569-581
• 26 Troll GF. Regional ophthalmic anesthesia: safe techniques and avoidance of complications. J Clin Anesth 1995; 7: 163-172
• 27 Hay A, Flynn jr. HW, Hoffman JI et al. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991; 98: 1017-1024
• 28 Duker JS, Belmont JB, Benson WE et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia. Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991; 98: 519-526
• 29 Berglin L, Stenkula S, Algvere PV. Ocular perforation during retrobulbar and peribulbar injections. Ophthalmic Surg Lasers 1995; 26: 429-434
• 30 Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986; 12: 182-184
• 31 Waller SG, Taboada J, OʼConnor P. Retrobulbar anesthesia risk. Do sharp needles really perforate the eye more easily than blunt needles?. Ophthalmology 1993; 100: 506-510
• 32 Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978; 86: 61-64
• 33 Wearne MJ, Flaxel CJ, Gray P et al. Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia. Ophthalmology 1998; 105: 371-376
• 34 Hamilton RC. A discourse on the complications of retrobulbar and peribulbar blockade. Can J Ophthalmol 2000; 35: 363-372
• 35 Schrader WF, Schargus M, Schneider E, Josifova T. Risks and sequelae of scleral perforation during peribulbar or retrobulbar anesthesia. J Cataract Refract Surg 2010; 36: 885-889
• 36 Katsev DA, Drews RC, Rose BT. An anatomic study of retrobulbar needle path length. Ophthalmology 1998; 96: 1221-1224
• 37 Pautler SE, Grizzard WS, Thompson LN et al. Blindness from retrobulbar injection into the optic nerve. Ophthalmic Surg 1986; 17: 334-337
• 38 Tappeiner C, Garweg JG. Retinal vascular occlusion after vitrectomy with retrobulbar anesthesia-observational case series and survey of literature. Graefes Arch Clin Exp Ophthalmol 2011; 249: 1831-1835
• 39 Wong DH. Regional anaesthesia for intraocular surgery. Can J Anaesth 1993; 40: 635-657
• 40 Hamed LM. Strabismus presenting after cataract surgery. Ophthalmology 1991; 98: 247-252
• 41 Rainin EA, Carlson BM. Postoperative diplopia and ptosis. A clinical hypothesis based on the myotoxicity of local anesthetics. Arch Ophthalmol 1985; 103: 1337-1339
• 42 Hofmann P, Metterlein T, Bollwein G. The myotoxic effects of bupivacaine and ropivacaine on myotubes in primary mouse cell culture and an immortalized cell line. Anesth Analg 2013; 117: 634-640
• 43 Zink W, Seif C, Bohl JR et al. The acute myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blockades. Anesth Analg 2003; 97: 1173-1179
• 44 Ropo A, Ruusuvaara P, Nikki P. Ptosis following periocular or general anaesthesia in cataract surgery. Acta Ophthalmol (Copenh) 1992; 70: 262-265
• 45 Nicoll JM, Acharya PA, Ahlen K et al. Central nervous system complications after 6000 retrobulbar blocks. Anesth Analg 1987; 66: 1298-1302
• 46 Hamilton RC. Brain-stem anesthesia as a complication of regional anesthesia for ophthalmic surgery. Can J Ophthalmol 1992; 27: 323-325
• 47 Drysdale DB. Experimental subdural retrobulbar injection of anesthetic. Ann Ophthalmol 1984; 16: 716-718
• 48 Kobet KA. Cerebral spinal fluid recovery of lidocaine and bupivacaine following respiratory arrest subsequent to retrobulbar block. Ophthalmic Surg 1987; 18: 11-13
• 49 Korevaar WC, Burney RG, Moore PA. Convulsions during stellate ganglion block: a case report. Anesth Analg 1979; 58: 329-330
• 50 Corman SL, Skledar SJ. Use of lipid emulsion to reverse local anesthetic-induced toxicity. Ann Pharmacother 2007; 41: 1873-1877
• 51 Taylor C, Wilson FM, Roesch R et al. Prevention of the oculo-cardiac reflex in children. Comparison of retrobulbar block and intravenous atropine. Anesthesiology 1963; 24: 646-649
• 52 Meyers EF. Complications in ophthalmic Surgery. In: Kruoin T, ed. Anaesthesia. 2nd ed. Philadelphia: JB Lippincott; 1984: 1-22
• 53 Wenger S. A retrobulbar catheter technique in ophthalmic regional anesthesia – a cadaver study. Med thesis. Bern: Faculty of Medicine, University of Bern; 2014: 27-28